As the world reached seven billion on October 31, what do we see as our own population realities and our own future? Today we can see sheer population size visibly impacting daily lives, making it difficult to find housing, shelter, jobs, gas, and most critically water and food. We therefore ask those who have the power and influence to change things — our planners, policy makers and politicians — whether they are aware of these realities. Pakistan’s population size has increased more than fivefold from 34 million in 1951 to its current estimate of 180 million. By the end of the century we could have as many as 360 million Pakistanis on the planet. Surely this would present an insurmountable challenge to our already stark scarcity of resources. It is time to seriously take in this reality, debate and discuss the options for our future and to take action while we can. Ironically, Pakistan was one of the earliest countries to have a population policy. Making the connection between the well-being of Pakistan’s population and the country’s resources and size, General Ayub Khan first announced a policy emphatically and publicly in 1965. Civil society too showed advanced thinking: the Family Planning Association of Pakistan (FPAP) started its own voluntary non-governmental programme at that time. But while mortality declined in the 50s, fertility decline began as late as 1990, about 10 years later than in most of South Asia and at least 25 years after its clearly defined population policy. Past demographic trends are fairly well established, but there is considerable uncertainty about the future. This is evident in the differences between projections made by leading population organisations. The government of Pakistan, the Population Council 2011 and the UN projections provide quite different scenarios for the future. Until a full count of the census takes place next year, projections provide the best estimates of the numbers of Pakistanis. Estimates of Pakistan’s population in 2050 vary from 270 to 325 million. The speed of the fertility decline from our current levels of just under four children per woman to replacement fertility is of utmost importance. Fertility in Pakistan has been slow to change, unlike Bangladesh, Iran and most of Asia. Reduction in fertility and the speed of fertility decline are the main drivers of population growth. The main cause of differences between the projections lies in their assumptions about future levels of fertility. The UN 2010 predicts a faster decline to replacement fertility (when every couple will reproduce itself) than the Population Council 2011 projections. Between 1950 and 2000 the population of Pakistan was very young with about 60 percent below the age of 25 and the age structure changed little in the 20th century. However, large changes are also expected in the coming four decades. This projected change in age composition is the result of declining fertility: with fewer births, younger generations will become smaller than older generations. The population under age 15 has recently levelled off due to decline in fertility but the population of working ages 15-64 is large and rapidly growing. If employed productively the country will benefit (wielding the so-called demographic dividend). If many working age adults cannot find employment or are underemployed, there are likely to be adverse social, economic and even political consequences. Even if fertility could be miraculously brought to replacement level today, population growth would continue as in most countries in the developing world. Future population growth will continue mainly due to the surge in the youth population as it passes through its reproductive ages. Further growth over the coming decades is guaranteed. This effect on future growth is called population momentum. What is most striking and important for us to realise is that even with instant attainment of replacement fertility, the population of Pakistan is still expected to grow an additional 90 million over the next four decades. The reason for more than half of all population growth between now and 2050 is almost entirely attributable to the momentum inherent in the young age structure of the country. In Pakistan 37 percent of married women are estimated to have an unmet need. Contraceptive use has increased substantially over the past two decades, reaching 30 percent in 2007. However, unmet need has risen more substantially, but not as much as the demand for contraception. Obstacles such as lack of access to family planning, fear of side effects of contraceptive methods, husbands’ disapproval, etc, lead some women to forgo contraceptive use despite their intention not to get pregnant. Such women have an ‘unmet need’ for contraception. About seven million pregnancies occurred in Pakistan in previous years and 39 percent (2.7 million) were unintended. If Pakistan were to invest in a strong family planning programme with a wide array of services of high quality it could expect to avoid as many as 37 percent of unintended births and a large portion of the million induced abortions. Unwanted childbearing is more common among poor, rural and uneducated women than among their well-off, urban and educated counterparts. Unwanted fertility varies from 1.6 to 0.6 children between the poorest and wealthiest quintiles. Family planning services located in poorer and rural areas can eliminate unwanted fertility. Wanted fertility comprises all births that women have until they achieve their desired family size. According to the 2006-07 Pakistan DHS the wanted total fertility rate was 3.2 births per woman. This implies that our current fertility of about four births per woman is 33 percent higher than it should be. There is also wide variation in wanted fertility: among the very educated in urban areas it is close to replacement while the rural poor still want close to five births. Similar differences exist across educational groups. Women with higher socioeconomic status marry later, use contraception more effectively, have more knowledge about and access to contraception, have greater autonomy in reproductive decision-making, and are more motivated to implement their preferences. To reduce inequalities in wanted fertility, Pakistan will have step up access to female education, and to redress income inequalities. Can we change our destiny? We certainly can try. The main opportunity lost is that we have had no comprehensive population policy but we can still take some important actions to address population growth rates today. This article and its contents are a clarion call for immediate multiple approaches that address each of the components of growth: Foremost, family planning programmes can reduce the unmet need for contraception by providing access to a range of birth control and spacing methods. In addition they provide information about methods and their benefits through IEC programmes that reduce obstacles to contraceptive use. This impact can be large; a small change in fertility can have a large impact on future population size. An imperative action is the inclusion of the health sector spread of services in both private and public sectors to deliver family planning services. At the moment, with the exception of the lady health workers, their contribution is fairly minimal. Doctors and paramedics are largely untrained and also unwilling to provide much demanded family planning services. If no further investment in family planning is made then fertility trajectory could easily be a half birth higher. Then Pakistan would reach 342 million in 2050. On the other hand, if a renewed investment in family planning is made, the future fertility trajectory could easily be a half birth less leading to 266 million by 2050. In other words the difference between a very weak and a strong family planning programme scenario is 76 million additional Pakistanis by 2050. High demand for children therefore remains a fundamental cause of population growth. Declines in wanted fertility usually occur with improvements in socioeconomic conditions as rising levels of income, education, and urbanisation reduce the benefits and raise the cost of childbearing and are highly responsive to improvements in human development, in particular in female education and child survival. Some poor societies such as Sri Lanka and Kerala in India, although poor, have high levels of literacy, female empowerment and very low infant and child mortality and wanted fertility. Improving the status of Pakistani women is an essential prerequisite for lowering wanted fertility. The key force behind population momentum can be achieved if the average age at which women begin childbearing rises (by delaying the first birth) and through wider spacing between births. Increasing the average age at childbearing by five years could reduce future population size by 20 percent. But young women in Pakistan often have little choice about when or whom to marry, and whether to defer childbearing. The early onset of fertility and the close spacing of births present health risks to young women, limits their education and livelihood possibilities. The longer girls stay in school, the later they marry and the greater the power in a marriage to delay or space childbearing. Delaying the onset of childbearing will significantly impact their lives. Pakistan is at a critical juncture in its demographic transition. After decades of very rapid population growth, the prospect of slower growth lies ahead because fertility is declining. But the timing and extent of further fertility declines is critical for Pakistan’s future. The population projected for 2050 may reach 395 million if no further fertility decline occurs and could be much lower at 266 million if fertility decline is rapid. The call for action to expedite the fertility transition is now. The writers are the Vice President and Distinguished Scholar, Population Council, New York, Country Director and Director Research at the Population Council, Islamabad